Failure to Promptly Notify Physician of Critical X-Ray Results
Summary
Facility staff failed to promptly notify the ordering physician of radiology results for a resident who fell and sustained a fracture. Resident #243, who had mild cognitive impairment and no prior falls, fell while attempting to hug another resident. The physician ordered x-rays for the resident's left hip and knee, which were conducted the following day. The x-ray results indicated a fracture of the neck of the proximal femur, but the day shift nurse only reported the knee results to the Physician's Assistant and did not inform them of the hip fracture. The night shift nurse and nursing supervisor both documented the fracture in their notes but did not notify the resident's physician or representative. It was not until the following day, approximately 21 hours later, that the primary care physician and the resident's representative were informed of the x-ray results. The resident was then transferred to the nearest emergency room for further evaluation. Interviews with the involved staff revealed a lack of clarity and communication regarding the notification process for critical results. The night shift nursing supervisor mentioned that there was no on-call list and that they were instructed not to call medical doctors during the night unless it was an emergency. The Medical Director, however, stated that he was available 24/7 and that any critical results affecting a resident's well-being should be reported immediately.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of falls and medical conditions experienced a delay in diagnostic testing and treatment for a suspected ankle injury. An x-ray ordered by a nurse practitioner was not entered into the system for nine hours, and the results indicating a fracture were not reported to the practitioner until eleven hours later, delaying treatment. This incident highlights a failure to adhere to the facility's policy on timely care for changes in resident conditions.
Delayed Diagnostic Test and Treatment for Resident's Injury
Penalty
Summary
The facility failed to ensure timely ordering, reporting, and treatment initiation for a diagnostic test for a suspected injury in a resident. The resident, who was at high risk for falls due to deconditioning and balance issues, had a history of falls and was admitted with conditions including acute embolism, thrombosis, encephalopathy, and type two diabetes. On a specific date, a nurse practitioner ordered an x-ray for the resident's left ankle due to pain and swelling, but the order was not entered into the electronic record until nine hours later. The x-ray results, which revealed an acute distal fibular fracture, were not reported to the nurse practitioner until eleven hours after the report was available. This delay in communication resulted in a further delay in treatment, as the nurse practitioner did not give orders to send the resident to the hospital until the following morning. Interviews with staff revealed inconsistencies in awareness of the resident's condition, with some staff unaware of the resident's complaints or the swelling prior to the x-ray order. The facility's policy on resident change in condition emphasizes timely and appropriate care when residents experience significant changes. However, the delay in ordering the x-ray, reporting the results, and initiating treatment for the resident's fracture indicates a failure to adhere to this policy. The deficiency was identified during an investigation of multiple complaints, highlighting a lapse in the facility's processes for managing changes in resident conditions.
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